Why the centre can’t hold

29 Apr 13

‘Command and control’ is the default position for politicians and public service managers. But, as the tragic failures in Mid-Staffordshire show, it is a deeply flawed delivery model

It is amazing how unprepared most new governments are when they take office. The current one had 13 years in opposition before winning power, while the previous Labour Government had to wait 18 years.

Even so, they are often slow to grasp how policy-making and the levers of power work in practice. Tony Blair admitted his first term in office was less than effective because of this latter problem.

The usual response by impatient politicians to this failure to effect change has been to increase centralised, command-and-control decision-making. The late Lady Thatcher, as many commentators have pointed out, was not exempt from this tendency.

On assuming office, one of the issues she faced was how to reform local government finance. The Layfield Report had suggested councils might be given tax-raising powers via a form of local income tax. But this was too much for the centralist Thatcher, who declared that she wanted local government to be financed 100% from the Exchequer. When told by colleagues this just wasn’t compatible with local democracy, she opted instead for the ‘poll tax’ – and the rest is history.

In the US, we might also ask whether President Barack Obama, despite his great rhetorical skills, has ever really understood the levers of power. An earlier US president, Harry S Truman, clearly did. He said that he didn’t get results by issuing orders from the White House. Instead, he spent time ‘kissing backsides to make things happen’.

Modern-day politicians, by contrast, fail to recognise that just issuing instructions from Whitehall rarely produces any responses, let alone the ones they want. More sophisticated approaches are needed.

But governments in many countries remain addicted to ‘command and control’. Those who have seen the TV series Yes, Minister and Yes, Prime Minister may recall civil servant Sir Humphrey urging minister James Hacker to resolve a particular problem with the words ‘Centralise, minister, centralise’. This series still remains a great primer for those who wish to understand Whitehall.

The roots of command-and-control lie in the military. It can be described as management based on the idea that people do what you tell them to do, and if they don’t, you yell at them until they do and if that doesn’t work, you apply some form of punishment. This probably sounds familiar to public service managers today.

But such a hierarchical, bureaucratic model is no longer fit for purpose in complex, sophisticated public services. In fact, it is often counter-productive. We see this in many failures of public policy. A prime example is the highly publicised scandal at the Mid Staffordshire NHS Foundation Trust, now in special administration, whose key weaknesses were exposed by the Francis Inquiry.

One of the inquiry’s conclusions was that it was difficult to apportion blame because it was hard to see who was actually in control. This is a typical feature of hierarchical command-and-control bureaucracies. At Mid Staffordshire, those at the top tended to be thought of as the ‘planners and thinkers’; those at the sharp end were the ‘doers’. Unfortunately, this asymmetry meant that senior managers had a restricted view of what was going on, while those at the bottom received inadequate instructions.

Another common factor in these hierarchies is that government and senior management respond to this lack of control by setting minimum performance standards. However, this target setting, and the monitoring and inspection that goes with it, is costly and ineffective.

The data and systems are often distorted to indicate apparent compliance. In the case of Mid Staffs, it was clear that targets set on accident and emergency waiting times meant patients were seen according to time constraints rather than clinical need.

In these circumstances, as it remains difficult for senior management to find out what is going on, there is a tendency to displacement of objectives. In the case of Mid Staffs, patient wellbeing was replaced by a ‘standard’ to indicate good performance: namely, achievement of trust status by management. Staff were rewarded for their efforts only when trust status was actually achieved. The assumption was that trust status was a reasonable proxy for patient care – it was not.

Where a command-and-control bureaucracy is a virtual monopoly supplier (as in NHS trusts) and clients are at an informational disadvantage compared with the professional (as in health care), organisations are frequently taken over by a ‘producer culture’. Those who manage and are employed in the organisation often believe that their interests and objectives are what matters and that they coincide with the public interest.

Such organisations find it difficult to cope with significant change. Instead they are best at delivering repeated levels of the same service. This means they are often poorly prepared to deal with natural variations in demand (as in the NHS), and find it difficult to implement multiple changes.

Meanwhile, the relentless pressure from senior managers to achieve performance targets and change management programmes, creates stress in the organisation. Hierarchical bureaucracies often tolerate dysfunctional behaviour because it is confused with strong and dynamic management, and indeed can promote behaviour that is bullying, self-seeking and deaf to complaints.

Perhaps the key issue at Mid Staffordshire was whether the situation was unique to that trust. In our view the command-and-control approach to running the NHS contains the seeds of such disastrous events. Robert Francis’s conclusion that what happened in Mid Staffordshire could happen elsewhere seems entirely probable.

One of the government’s responses to the Francis Report has been to commission a series of inquiries into other NHS trusts that show higher-than-expected death rates. No doubt it hopes that demographic factors, socioeconomic issues or the mix of conditions being treated will provide an explanation. However, by restricting the inquiries to the present rather than to historical problems, it has cut itself off from information from previous ‘whistleblowers’ in the organisations under investigation.

Depending on the outcome of those inquiries, the government will face a real dilemma. If the results show that Mid Staffs really was an aberration due to individual management failings, then the clamour from patient groups for someone to be held responsible will become more strident. On the other hand, if it is shown that the situation in Mid Staffs is replicated elsewhere, it implies a serious systemic problem. Ministers will have to address whether the pattern of organisation in the NHS is fit for purpose. And whether the current reforms – which involve trying to substitute patient and community interest for producer interests – will make a sufficient change.

The command-and-control model is an ineffective way to manage public services and cope with the demands for change implied by a prolonged period of financial austerity. New and radical models are needed.

Written by Malcolm Prowle and Roger Latham, respectively professor and visiting fellow at Nottingham Business School. They are also authors of Public services and financial austerity: getting out of the hole

  • Malcolm Prowle
    Malcolm Prowle

    Malcolm Prowle is professor of business performance at Nottingham Business School and a visiting research professor at the Open University Business School. Malcolm is an expert on the economics, finance and management of public services. He has advised ministers, senior civil servants and public service managers on a wide range of public policy and implementation issues.

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